LipidRescue™ Resuscitation

A 33 year old healthy man was scheduled for an ambulatory knee arthroscopy in general anaesthesia.At the end of the operation, the surgeon applied 15 ml Bupivacaine 0,25% intrarticularly for pain therapy, but the anaesthetist forgot to inform the PACU about the Bupivacaine.
20 minutes later in the PACU the patient developed the first neurological symptoms with signs of focal seizure starting with the left arm (without any history of epilepsia). He received 1 mg Midazolam i.v, but 5 minutes later started with generalized myoclonia again, with convergence of the eyes to the left side. However, the patient could open the eyes on command and move all extremities, but he was disorientated and somnolent.
After the second "seizure-like" period, we conducted an CT-scan of the brain to rule out an intracraniel or subarachnoidal bleeding, which was uneventful, but the patient was neurologically unchanged.
While initiating further monitoring in our ICU we were informed about the Bupivacaine-application. Immediately the patient received 50 ml 20% Lipidemulsion i.v.as bolus, followed by continous infusion of 50 ml per hour. Within 15 minutes the myoclonie stopped, and within the next 15 minutes, he became awake and all neurological symptoms vanished.
Despite the small amount of bupivacaine (37,5 mg) applied intra-articularly, bupivacaine toxicity seems to be the most plausible reason for these postoperative neurological symptoms, especially since the symptoms disappeared within 30 minutes after starting the intravenous Lipidemulsion.
Even surgically applied Bupivacaine can be very important for an anesthetist....

Thanks for posting the case, Christian. By the way, nice case report last year: the third published successful LipidRescue (even tho it was in a German journal).

This case brings up at least three important points that always deserve repeating.
1). 'Atypical' presentation of LA toxicity is common. Here, the late presentation made diagnosis more difficult.
2). Some patients are particularly sensitive to local anesthetic-induced toxicity. I reported a case some time ago in a pateint who got just 22mg bupivacaine SQ! So, dose shouldn't exclude the diagnosis.
3). Miscommunication is nearly always involved in medical complications.

Finally, i'm glad to see another example of successful LipidRescue from CNS symptoms of toxicity.